PURPOSE:Microvascular free tissue transfer has become main technique for head and neck reconstruction. We assessed the cost-effectiveness of free flap reconstruction for head and neck defects after oncologic resection for squamous cell cancer (SCC).METHODS:We developed a Markov model of the cost, quality of life, survival and incremental cost-effectiveness of reconstruction with free tissue transfer compared to pedicled flaps. Primary data includes all institutional cases of reconstruction after SCC resection between 2003 and 2013. Data from the literature and the Head and Neck Outcome Calculator were used to determine quality of life and survival. Outcomes included quality-adjusted survival, cost-effectiveness and incremental cost-effectiveness ratio.RESULTS:Free flap reconstruction was more costly than pedicled flap but associated with greater quality of life with no survival benefit. A value less than $50,000 per QALY was defined as cost-effective. The incremental cost-effectiveness for head and neck free flap reconstruction was $12,500 per quality-adjusted life-years gained. Reconstruction was more cost effective for patients with lower stage cancers: $5200 per QALY for stage I SCC, $7600 for Stage II, $16,600 for stage III and $31,900 for Stage IV. Sensitivity analysis showed the cost-effectiveness would remain below $40,000 for all stages of SCC.CONCLUSION:Microsurgical head and neck reconstruction is cost effective compared to pedicled flaps, even more so in patients with early stage cancer. This finding supports the current practice of free flap head and neck reconstruction. Screening and early detection are important to optimize costs.